Healthcare Provider Details

I. General information

NPI: 1114042108
Provider Name (Legal Business Name): GEORGIA OXYGEN PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 S GRANT ST
FITZGERALD GA
31750-3315
US

IV. Provider business mailing address

PO BOX 750
FITZGERALD GA
31750-0750
US

V. Phone/Fax

Practice location:
  • Phone: 229-424-0018
  • Fax:
Mailing address:
  • Phone: 229-424-0018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE008222
License Number StateGA

VIII. Authorized Official

Name: ED HILL
Title or Position: OWNER
Credential:
Phone: 229-423-7809